That’s basically what my son, Ray, was told when he and Annette recently took Maddie, four years old, to the doctor suggesting that she had appendicitis. It didn’t matter that all three of Ray’s brothers and one of his four sisters had undergone appendectomies, not to mention Maddie’s brother and a sister who already had their appendixes taken out. That skepticism, combined with Maddie’s high tolerance for pain, especially in a formal social situation, plus the fact that it is rare in 4-year-olds, led to being misdiagnosed with a UTI and ending up with a perforated appendix.
So this is why I’m writing this post. Just for the record: Appendicitis runs in our family. My former husband’s mom had an appendectomy while she was pregnant with him. So far, half of our eight kids have had that little tail on the large intestine cut off. Now, the only son who did not have it himself has passed it on to three of his five kids. So the numbers are becoming increasingly significant with 7/13 kids in the two families having acute appendicitis, the most common surgical emergency today.
I respect and appreciate doctors very much. Some of my family would not be here now were it not for doctors. It is interesting though that as important as family history is now days when it comes to heart disease and cancer, that some doctors still view with suspicion an inherited tendency for appendicitis. I remember being told pretty much the same thing back in the ’80’s when three of our children had their turn with it. We were thinking it had to be more than coincidence by the time the third incident happened.
Back then we didn’t have Google to confirm that appendicitis runs in families. For more information this website is a good one. Here’s something that was nice to see: “A genetic predisposition for appendicitis exists. A history of appendicitis in a first-degree relative is associated with a 3.5 to 10-fold relative risk for developing this disorder.”
Fortunately, all of our children presented with classic symptoms. Taber’s Cyclopedic Medical Dictionary states that “Classic presentations, which occur about 60% of the time, include abdominal pain (initially diffuse, gradually localizing to the right lower quadrant), loss of appetite, nausea, fever, and an elevated white blood cell count.”
I called and talked to my daughter, Emily, to refresh my memory on her case. She was the only one of our four who came close to being misdiagnosed. She was seven at the time and recalled how she was always excited to go places and socialize, and was just “too happy”, as the doctor observed. She laughed at his jokes and didn’t seem to be in much pain at all. She remembers waking up on a Saturday morning with her stomach hurting and then going to breakfast and trying to eat, but everything “seemed gross.” Her best friend came over later and stayed with her the whole day with Emily mostly just laying on the floor.
She recalls that evening being in the family room and hearing her dad and I chuckling and saying, “It couldn’t be appendicitis, we’ve already had two kids with appendicitis.” At that point in our thinking, the odds seemed to be reversed. Three kids in five or six years? No way! But as the pain localized more in the right side, we figured we’d better head for the hospital. She passed enough of the criteria, in spite of her very good nature, to have them check her white blood cell count.
The WBC is what stands out in my experience of having my children diagnosed with appendicitis. They do the WBC, it comes back high, and they proceed with surgery. I was surprised that with Maddie, they didn’t do that right away.
Here’s Maddie’s case history: Saturday, June 16 at 8:00 p.m. she threw up. She woke up on Sunday at about 7:45 complaining that her stomach hurt. She didn’t want to get out of bed, and when she did, she was bent over, holding her stomach. She also had a pretty high fever. Ray had Annette take Maddie to the hospital because he believed it was appendicitis. Because her symptoms were atypical–pain was not consistently localized over the RLQ, and she was able to perform tests such as hopping up and down (which usually isn’t possible with someone with appendicitis)– they figured it was a UTI. Maddie was given IV antibiotics and sent home around 11:30 a.m. They were instructed to come back if she got worse. Around 5:45 p.m. she had a temperature of 104.8 even though her next scheduled dose of Ibuprofen was not for two hours. They took her back to the hospital and got the impression from the first two doctors that they were wondering why they came back. The one doctor had scoffed at the notion that appendicitis can run in families and asked if all those family cases “were confirmed.”
Later a third doctor, who was more familiar with atypical presentation of appendicitis in young children, engaged Maddie in conversation and observed how she reacted when the nurse tried three times to get a needle in for some blood. She flinched a little. The doctor said, “She’s a tough one.” He said that even with the atypical results on the different tests, “I am not convinced that this is not appendicitis.” He then ordered the blood test for the white blood cell count and when it came back quite high, he scheduled an appendiceal CT scan. A second urine test came back negative for UTI. She had her scan at 11:00 p.m. and the doctor came back to tell them that it was appendicitis and that the radiologist believed it was perforated.
So Maddie had her surgery early the next morning. The surgeon said that it was “perforated but contained.” Her appendectomy was performed laparoscopically. She’s got three little scars and had a very speedy recovery. She was a real trooper. One of the hardest things for her was going so long without eating. Ray figures it was 66 hours from when she lost her appetite until she was able to have food and drink the normal way. We went to visit her Monday night and three or four times she said, “I want food” or “I’m hungry” and would almost cry but then she would just “deal with it” and watch her show and hold her stuffed animal. She wasn’t allowed anything til Tuesday morning. Whew!
Okay, just for fun, here is a guide to doing appendicitis the right way:
Be between the ages of 10 and 30. Don’t do it as an infant, you can’t report the pain. Don’t do it when elderly, the pain is often minimal. Your chances are better if you are a guy. Be able to describe the nature, timing, location, pattern, and severity of pain and symptoms. Demonstrate rebound tenderness and guarding. Rebound tenderness is when the doctor presses on a part of the abdomen and you feel more tenderness when the pressure is released than when it is applied. Guarding refers to the tensing of muscles in response to touch. Go ahead and be very guarded. Don’t appear to be enjoying yourself too much. It looks too suspicious. And finally, mention that all your siblings and your dad have already had their appendixes removed–it might get you somewhere but then again, maybe not!
August 2, 2007 at 1:38 pm
I love the guide to doing appendicitis right!!! I got a good laugh. It’s good to read the symptoms and stories again. Thanks, Mom.
August 3, 2007 at 7:36 am
Nice job, mom. I wish I’d had Annette read the info I sent you before I sent it. I’m male, so my memory is . . . well, not as good as if I weren’t. She reminded me, though, that the doctor had Maddie jumping up and giving him “high-fives” which she was able to do–I can only imagine (not having had appendicitis myself) how difficult it could be for a kid who has difficulty just straightening up while standing or lying down!
I really appreciated your info on that site. If only I had the email address of that second-to-last doctor . . .
And, like Em, I really enjoyed the guide as well. Thanks Mom.
August 10, 2007 at 10:34 am
Em–Thanks and you’re welcome! I appreciated you telling me your story again so I could include some details since I don’t seem to have a memory for details–not sure what my excuse is since I’m not male, like Ray–
.
Ray–Thanks for giving me all the info that you did. I am glad you put that in your comment about Maddie jumping up and giving the doctor “high-fives.” Maddie sure does have a “can do” attitude. She just wanted to meet the challenge and she did!
June 17, 2009 at 9:21 am
My 4 year old son has been complaining of his tummy hurting maby onec a day for the last week. For the last few months he has been sick with high fever,vomit, and tummy pain. almost every other week we have been taking him to the dr. They keep telling us it is a flu, and that he started pre school and that they get sick a lot. But my husband had his appendicitis removed a 3 or 4 years old, and also a aunt and cousin had theirs removed at the same time. It makes me worrie that they might be missing something. my sons feaver is usually around 104′. Do you have any suggestions? Thanks sjtxoxo@yahoo.com
June 17, 2009 at 11:55 am
Hi Shaya–If the doctor hasn’t already done it, he or she should check the white blood cell count. That is a real determining factor for appendicitis.
It certainly does not sound like the flu as that doesn’t keep recurring like that.
That’s the main thing I would say. Good luck on getting it diagnosed for the little guy!
June 17, 2009 at 4:26 pm
In case anyone could use some more in-depth explanations of appendicitis symptoms, etc, I will forward this with my son’s permission. This was his response to my request after hearing from Shaya:
Mom, To have a really good understanding of what doctors do to determine what is causing the problem, it’s helpful to understand the concept of “differential diagnosis,” which essentially means that based upon the symptoms that are present, there are a number of possible causes for the symptoms. If the symptom is something quite general, say like abdominal pain, then the differential diagnosis could include all sorts of things, from things that are not serious at all (minor intestinal virus) to those which are life-threatening (appendicitis, pancreatitis, etc.). The more information the doctor receives, based upon medical history, examination, lab results, etc., the more refined the list of possible causes becomes. A doctor will first eliminate the possibility of it being a life-threatening condition. If that happens, usually by negative test results–they may not try much else–because neither you or your insurance company want to have to pay for unnecessary tests or hospitalizations, and if it isn’t life-threatening, then why go to the trouble? Really, it’s only a more elaborate form of the same decision-making process any parent goes through before taking their child to the doctor. First obviously your child is in pain, so, is it time to take them to the doctor? Well, that depends. Where are they hurting? Did they experience any type of fall or other trauma to the affected area? Are they throwing up? Feeling like throwing up? A fever? As parents with three children who have had their appendices removed (as well as my having 4 siblings who have had the operation) , we recognized the symptoms of appendicitis quite quickly:
Abdominal pain–usually starting in the middle of the stomach around the belly button, then later moving on to the lower right quadrant.
Nausea.
Walking/lying on their sides hunched over. Kids are usually more easy to read by their physical actions (when they don’t know you’re watching) than by what they tell you. Depending upon age, they may not have the vocabulary to tell you exactly what you need to know. Also, for younger children, the desire to please a parent ranks higher than providing accurate information. A well-meaning parent can inadvertently “lead” the child to say what the parent starts to think is happening, because what the parent asks, and the way she asks it may lead the child to believe that the parent wants a specific answer: “honey, does it hurt here?” rather than “honey, where does it hurt?”
Fever. Usually the fever for us was not very high–101-102, definitely not in the 104 range (but again, some kids naturally have consistently higher fevers than others (my second child was that way with the chicken pox, with urinary tract infections, and with the flu).
Basically, these symptoms for us were the indicators that we used to definitely take our kids to the emergency room, not the clinic.
Other things that the doctor might use to eliminate life-threatening conditions from the differential diagnosis is one of various illness-specific tests. With appendicitis the doctor will often check for “rebound tenderness.” This test is performed by pushing in on the area over where the appendix is located and then quickly releasing the pressure–which if appendicitis is present is more painful than the pushing (though the pressure is uncomfortable, too). Other appendicitis-specific tests include having the child hop or jump in place. The doctor will also be observing to see if there is “guarding” which is an involuntary tension in the muscles over the area in reaction to pressure.
Of course, there are the lab tests. The doctor will first do a urine test–checking for the evidence of white-blood cells and protein in the urine. If white cells are indicated, the doctor will usually follow that with a blood test. An elevated White Blood Count (WBC) is an indication of infection.
If these tests do not reassure the doctor that nothing life-threatening is happening, he may order tests from radiology, which will usually involve some kind of contrast to show what’s going on inside. That was the only way with our youngest appy victim that they were certain it was appendicitis.
(An explanation here–young children may or may not respond to all of the other clinical tests in the classic manner–they may not experience, for example, as much localized pain in the lower-right quadrant. Our daughter was able to hop, endure the rebound tenderness test, and so forth without much reaction–it took an experienced doctor (with the aid of two sets of blood tests) to finally realize that she was a pretty tough kid. He decided to perform the other tests when she was distracted, and it was a little wince while she was in deep conversation with someone else–and no more–that led him to conduct the radiography contrast test which confirmed that she had a perforated appendix.
One thing to note is that usually appendicitis is an acute illness (meaning that the onset and progression of the disease is quick (over the course of hours-not days or weeks)) and not a chronic condition. One of the explanations I’ve heard for why appendicitis happens is that the opening of the appendix into the colon becomes blocked, not allowing the body to expel matter that is in the appendix, which in turn results in the swelling (then later, if not caught the “perforation” or bursting of the appendix). With symptoms that span over weeks and even up to a month, a doctor would likely eliminate acute appendicitis from the differential diagnosis.